Aroosa Zamarud, MD

All Publications

• Deep learning-based overall survival prediction in patients with glioblastoma: An automatic end-to-end workflow using pre-resection basic structural multiparametric MRIs. Computers in biology and medicine Yang, Z., Zamarud, A., Marianayagam, N. J., Park, D. J., Yener, U., Soltys, S. G., Chang, S. D., Meola, A., Jiang, H., Lu, W., Gu, X. 2024; 185: 109436

  Abstract

  Accurate and automated early survival prediction is critical for patients with glioblastoma (GBM) as their poor prognosis requires timely treatment decision-making. To address this need, we developed a deep learning (DL)-based end-to-end workflow for GBM overall survival (OS) prediction using pre-resection basic structural multiparametric magnetic resonance images (Bas-mpMRI) with a multi-institutional public dataset and evaluated it with an independent dataset of patients on a prospective institutional clinical trial.The proposed end-to-end workflow includes a skull-stripping model, a GBM sub-region segmentation model and an ensemble learning-based OS prediction model. The segmentation model utilizes skull-stripped Bas-mpMRIs to segment three GBM sub-regions. The segmented GBM is fed into the contrastive learning-based OS prediction model to classify the patients into different survival groups. Our datasets include both a multi-institutional public dataset from Medical Image Computing and Computer Assisted Intervention (MICCAI) Brain Tumor Segmentation (BraTS) challenge 2020 with 235 patients, and an institutional dataset from a 5-fraction SRS clinical trial with 19 GBM patients. Each data entry consists of pre-operative Bas-mpMRIs, survival days and patient ages. Basic clinical characteristics are also available for SRS clinical trial data. The multi-institutional public dataset was used for workflow establishing (90% of data) and initial validation (10% of data). The validated workflow was then evaluated on the institutional clinical trial data.Our proposed OS prediction workflow achieved an area under the curve (AUC) of 0.86 on the public dataset and 0.72 on the institutional clinical trial dataset to classify patients into 2 OS classes as long-survivors (>12 months) and short-survivors (<12 months), despite the large variation in Bas-mpMRI protocols. In addition, as part of the intermediate results, the proposed workflow can also provide detailed GBM sub-regions auto-segmentation with a whole tumor Dice score of 0.91.Our study demonstrates the feasibility of employing this DL-based end-to-end workflow to predict the OS of patients with GBM using only the pre-resection Bas-mpMRIs. This DL-based workflow can be potentially applied to assist timely clinical decision-making.

  View details for DOI 10.1016/j.compbiomed.2024.109436

  View details for PubMedID 39637462

• Poor venous outflow is associated with hyperintense acute reperfusion marker on follow-up MRI in patients with acute ischemic stroke with a large vessel occlusion. Journal of neurointerventional surgery Zamarud, A., Yuen, N., Wouters, A., Mlynash, M., Hugdal, S. M., Seners, P., Kesten, J., Yedavalli, V., Faizy, T. D., Albers, G. W., Lansberg, M. G., Heit, J. J. 2024

  Abstract

  Hyperintense acute reperfusion marker (HARM) refers to delayed enhancement in the subarachnoid or subpial space on post-contrast fluid attenuated inversion recovery (FLAIR) images. HARM is a measure of blood-brain barrier breakdown, which has been correlated with poor outcomes in patients with acute ischemic stroke with large vessel occlusion (AIS-LVO). We hypothesized that unfavorable venous outflow (VO) would be correlated with HARM after thrombectomy treatment of AIS-LVO.To determine whether poor VO is associated with HARM on follow-up MRI after stroke in patients with AIS-LVO.Patients with AIS-LVO from the prospective CRISP2 and DEFUSE2 studies with a baseline CT angiography (CTA) scan and a follow-up MRI with FLAIR sequence were screened for enrollment. VO was measured on the baseline CTA scan using the cortical venous opacification score (COVES). HARM was determined on FLAIR sequences at the follow-up MRI. The primary outcome was the occurrence of HARM between those with good VO (VO+; COVES 3-6) and bad VO (VO-; COVES 0-2).121 patients were included; 60.3% (n=73) had VO+ and 39.7% (n=48) had VO-. Patients with VO- had higher presentation National Institutes of Health Stroke Scale scores (18 (IQR 12-20) vs 12 (IQR 8-16) in VO+; P<0.001). Middle cerebral artery M1 segment occlusions were more common in VO- patients (65% vs 43% VO+; P=0.028). VO- patients also had a larger pre-treatment ischemic core (23 (4-44) mL vs 12 (3-22) mL in VO+; P=0.049) and Tmax >6 s volumes (105 (72-142) mL vs 66 (35-95) mL in VO+; P<0.001). VO- patients were more likely to develop HARM after thrombectomy (31% vs 10% in VO+; P=0.003). On multivariable regression analysis, VO- (OR=3.6 (95% CI 1.2 to 10.6); P=0.02) and the presence of any ICH (OR=3.6 (95% CI 1.2 to 10.5); P=0.02) were independently associated with the occurrence of HARM.In patients with AIS-LVO, VO- correlated with HARM on post-thrombectomy MRI.

  View details for DOI 10.1136/jnis-2024-022064

  View details for PubMedID 39393917

• Clinical and Perfusion Imaging Characteristics of Acute Large Vessel Occlusion in Intracranial Atherosclerosis: Clinical and Perfusion Imaging in ICAD-LVO. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association Liu, H. Y., Heit, J. J., Yuen, N., Yang, C. H., Mlynash, M., Zamarud, A., Lun, R., Lansberg, M. G., Albers, G. W. 2024: 108024

  Abstract

  This study aimed to compare clinical and perfusion imaging profiles in acute ischemic stroke with large vessel occlusion (AIS-LVO) between patients with intracranial atherosclerotic disease (ICAD) and non-ICAD who underwent endovascular treatment (EVT).Data from AIS-LVO patients over the anterior circulation undergoing EVT across two stroke centers were retrospectively analyzed. Clinical profiles and perfusion parameters from automated processing of perfusion imaging were compared between ICAD and non-ICAD groups. Ischemic core was defined as relative cerebral blood flow < 30% on CT perfusion or apparent diffusion coefficient ≤ 620  ×  10-6 mm2/s on MR diffusion weighted imaging.A total of 111 patients were included (46 ICAD, 65 non-ICAD). The ICAD group exhibited a higher male proportion (60.9% vs. 35.4%), more M1 segment occlusions (78.3% vs. 56.9%), lower atrial fibrillation rates (17.4% vs. 63.1%), and lower baseline NIH Stroke Scale (NIHSS) scores (median [IQR]: 13 [8.75-18] vs. 15 [10-21]) at presentation compared to non-ICAD (all p< 0.05). However, there was no difference in NIHSS scores at discharge or in good functional outcomes (modified Rankin Scale 0-2) at 3 months between the two groups. ICAD patients also had smaller median ischemic core volumes (0 [IQR 0-9.7] vs. 4.4 [0-21.6] ml, p=0.038), smaller median Tmax >6s tissue volulmes (89.3 [IQR 51.1-147.1] vs. 124.4 [80.5-178.6] ml, p=0.017) and lower median HIR (hypoperfusion intensity ratio defined as Tmax >10s divided by Tmax >6s; 0.28 [IQR 0.09-0.42] vs. 0.44 [0.24-0.60], p=0.003). Higher baseline NIHSS scores correlated with larger Tmax >6s lesion volumes as well as higher HIR value in non-ICAD patients, but not in ICAD patients.In anterior circulation of AIS-LVO, ICAD patients exhibited distinct clinical presentations and perfusion imaging characteristics when compared to non-ICAD patients. Perfusion imaging profiles may serve as indicators for identifying ICAD patients before EVT.

  View details for DOI 10.1016/j.jstrokecerebrovasdis.2024.108024

  View details for PubMedID 39303867

• Perfusion imaging for delayed cerebral ischemia detection in patients following ruptured aneurysmal subarachnoid hemorrhage: Interrater reliability assessment. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences Bombardieri, A. M., Wouters, A., Seners, P., Zamarud, A., Mlynash, M., Yuen, N., Albers, G. W., Sussman, E. S., Pulli, B., Lansberg, M. G., Steinberg, G. K., Heit, J. J. 2024: 15910199241277953

  Abstract

  Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) is associated with adverse neurological outcomes. Early and accurate diagnosis of DCI is crucial to prevent cerebral infarction. This study aimed to assess the diagnostic accuracy and interrater agreement of the visual assessment of neuroimaging perfusion maps to detect DCI in patients suspected of vasospasm after aSAH.In this case-control study, cases were adult aSAH patients with DCI who underwent magnetic resonance perfusion or computed tomography perfusion (CTP) imaging in the 24 h prior to digital subtraction angiography for vasospasm diagnosis. Controls were patients with dizziness and no aSAH on CTP imaging. Three independent raters, blinded to patients' clinical information, other neuroimaging studies, and angiographic results, visually assessed anonymized perfusion color maps to classify patients as either having DCI or not. Tmax delay was classified by symmetry into no delay, unilateral, or bilateral.Perfusion imaging of 54 patients with aSAH and 119 control patients without aSAH was assessed. Sensitivities for DCI diagnosis ranged from 0.65 to 0.78, and specificities ranged from 0.70 to 0.87, with interrater agreement ranging from 0.60 (moderate) to 0.68 (substantial).Visual assessment of perfusion color maps demonstrated moderate to substantial accuracy in diagnosing DCI in aSAH patients.

  View details for DOI 10.1177/15910199241277953

  View details for PubMedID 39219541

• Stereotactic Radiosurgery for Residual, Recurrent, and Metastatic Hemangiopericytomas: A Single-Institution Retrospective Experience. Neurosurgery Yoo, K. H., Park, D. J., Veeravagu, A., Persad, A., Lee, M., Marianayagam, N. J., Zamarud, A., Gu, X., Pollom, E. L., Soltys, S. G., Meola, A., Chang, S. D. 2024

  Abstract

  BACKGROUND AND OBJECTIVES: Hemangiopericytomas are infrequent vascular tumors originating from Zimmermann pericytes. The conventional treatment involves gross total resection, followed by adjuvant radiotherapy. Nevertheless, their tendency to infiltrate dural sinuses, high vascularity, and anatomic complexity pose challenges for radical resection, leading to a significant risk of recurrence. Stereotactic radiosurgery (SRS) has emerged as a promising adjuvant therapy to address these challenges. Our study provides the largest single-institutional retrospective, aiming to evaluate the effectiveness and safety of SRS as a treatment modality for residual, recurrent, and metastatic hemangiopericytomas.METHODS: From 1998 to 2023, 27 patients with 101 tumors underwent CyberKnife SRS at Stanford University Medical Center. The median age was 51 years at the time of treatment. The median follow-up period from SRS was 103 months (range: 6-250). All patients underwent upfront surgical resection. The median tumor volume was 1.5 cc. The median single-fraction equivalent dose was 19 Gy. The SRS was administered at the 76% of the median isodose line (range: 64-89).RESULTS: Of the 101 treated tumors, 24 (23.8%) progressed with a median time to recurrence of 30 months. At 10 years, the rates of local tumor control (LTC), overall survival (OS), and progression-free survival (PFS) were 74.3%, 80.8%, and 67%, respectively. In patients with metastatic lesions, the LTC rates were significantly greater when compared with those with residual or recurrent tumors. There was no significant difference between patients with residual, recurrent, and metastatic hemangiopericytomas in OS and PFS. Notably, no cases of radiation-induced adverse events were detected.CONCLUSION: SRS leads to excellent LTC, PFS, and OS at 10 years with negligible risk for adverse events. Therefore, it is an effective and safe management modality for patients with residual, recurrent, and metastatic hemangiopericytomas.

  View details for DOI 10.1227/neu.0000000000003114

  View details for PubMedID 39028180

• Advancing diagnostic precision of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: The potential for a vasospasm index score on perfusion imaging to detect vasospasm. European journal of radiology Maria Bombardieri, A., Seners, P., Wouters, A., Zamarud, A., Mlynash, M., Yuen, N., Albers, G. W., Sussman, E. S., Pulli, B., Lansberg, M. G., Steinberg, G. K., Heit, J. J. 2024; 178: 111578

  Abstract

  The occurrence of delayed cerebral ischemia and vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) results in high morbidity and mortality, but the diagnosis remains challenging. This study aimed to identify neuroimaging perfusion parameters indicative of delayed cerebral ischemia in patients with suspected vasospasm.This is a case-control study. Cases were adult aSAH patients who underwent magnetic resonance perfusion or computed tomography perfusion (CTP) imaging ≤ 24 h before digital subtraction angiography performed for vasospasm diagnosis and treatment. Controls were patients without aSAH who underwent CTP. Quantitative perfusion parameters at different thresholds, including Tmax 4-6-8-10 s delay, cerebral blood flow and cerebral blood volume were measured and compared between cases and controls. The Vasospasm Index Score was calculated as the ratio of brain volume with time-to-max (Tmax) delay > 6 s over volume with Tmax > 4 s.54 patients with aSAH and 119 controls without aSAH were included. Perfusion parameters with the strongest prediction of vasospasm on cerebral angiography were the combination of the Vasospasm Index Score (Tmax6/Tmax4) + CBV ≤ 48 % (area under the curve value of 0.85 [95 % CI 0.78-0.91]) with a sensitivity of 63 % and specificity of 95 %.The Vasospasm Index Score in combination with CBV ≤ 48 % on cerebral perfusion imaging reliably identified vasospasm as the cause of DCI on perfusion imaging.

  View details for DOI 10.1016/j.ejrad.2024.111578

  View details for PubMedID 38981177

• The Role of CyberKnife Stereotactic Radiosurgery in Recurrent Cranial Medulloblastomas across Pediatric and Adult Populations. Journal of clinical medicine Yoo, K. H., Marianayagam, N. J., Park, D. J., Zamarud, A., Gu, X., Pollom, E., Soltys, S. G., Meola, A., Chang, S. D. 2024; 13 (12)

  Abstract

  Background/Objectives: Medulloblastoma is the most common malignant brain tumor in children. In recent decades, the therapeutic landscape has undergone significant changes, with stereotactic radiosurgery (SRS) emerging as a promising treatment for recurrent cases. Our study provides a comprehensive analysis of the long-term efficacy and safety of SRS in recurrent medulloblastomas across both pediatric and adult patients at a single institution. Methods: We retrospectively reviewed the clinical and radiological records of patients who underwent CyberKnife SRS for recurrent cranial medulloblastomas at our institution between 1998 and 2023. Follow-up data were available for 15 medulloblastomas in 10 patients. The cohort comprised eight pediatric patients (ages 3-18) and two adult patients (ages 19-75). The median age at the time of SRS was 13 years, the median tumor volume accounted for 1.9 cc, the median biologically equivalent dose (BED) was 126 Gy, and the single-fraction equivalent dose (SFED) was 18 Gy. The SRS was administered at 75% of the median isodose line. Results: Following a median follow-up of 39 months (range: 6-78), 53.3% of the medulloblastomas progressed, 13.3% regressed, and 33.3% remained stable. The 3-year local tumor control (LTC) rate for all medulloblastomas was 65%, with lower rates observed in the adult cohort (50%) and higher rates in pediatric patients (67%). The 3-year overall survival (OS) rate was 70%, with significantly higher rates in pediatric patients (75%) compared to adult patients (50%). The 3-year progression-free survival (PFS) rate was 58.3%, with higher rates in pediatric patients (60%) compared to adult patients (50%). Two pediatric patients developed radiation-induced edema, while two adult patients experienced radiation necrosis at the latest follow-up, with both adult patients passing away. Conclusions: Our study provides a complex perspective on the efficacy and safety of CyberKnife SRS in treating recurrent cranial medulloblastomas across pediatric and adult populations. The rarity of adverse radiation events (AREs) underscores the safety profile of SRS, reinforcing its role in enhancing treatment outcomes. The intricacies of symptomatic outcomes, intertwined with factors such as age, tumor location, and prior surgeries, emphasize the need for personalized treatment approaches. Our findings underscore the imperative for ongoing research and the development of more refined treatment strategies for recurrent medulloblastomas. Given the observed disparities in treatment outcomes, a more meticulous tailoring of treatment approaches becomes crucial.

  View details for DOI 10.3390/jcm13123592

  View details for PubMedID 38930121

• Stereotactic Radiosurgery for Ependymoma in Pediatric and Adult Patients: A Single-Institution Experience. Neurosurgery Yoo, K. H., Marianayagam, N. J., Park, D. J., Persad, A., Zamarud, A., Shaghaghian, E., Tayag, A., Ustrzynski, L., Emrich, S. C., Gu, X., Ho, Q. A., Soltys, S. G., Meola, A., Chang, S. D. 2024

  Abstract

  Ependymoma is commonly classified as World Health Organization grade 2 with the anaplastic variant categorized as grade 3. Incomplete resection or anaplastic features can result in unfavorable outcomes. Stereotactic radiosurgery (SRS) provides a minimally invasive approach for recurrent ependymomas. Our study investigates the efficacy and safety of SRS for grade 2 and 3 ependymomas in pediatric and adult populations.We conducted a retrospective analysis on 34 patients with 75 ependymomas after CyberKnife SRS between 1998 and 2023. Fourteen were pediatric (3-18 years), and 20 were adult (19-75 years) patients. The median age was 21 years, and the median tumor volume was 0.64 cc. The median single-fraction equivalent dose was 16.6 Gy, with SRS administered at 77% of the median isodose line.After a median follow-up of 42.7 months (range: 3.8-438.3), 22.7% of ependymomas progressed. The 5-year local tumor control rate was 78.1%, varying between 59.6% and 90.2% for children and adults, with grade 2 at 85.9% compared with 58.5% for grade 3 tumors. The 5-year overall survival rate was 73.6%, notably higher in adults (94.7%) than in children (41%), and 100% for grade 2 but decreased to 35.9% for grade 3 patients. The 5-year progression-free survival rate was 68.5%, with 78.3% and 49.2% for adults and children, respectively, and a favorable 88.8% for grade 2, contrasting with 32.6% for grade 3 patients. Symptom improvement was observed in 85.3% of patients. Adverse radiation effects occurred in 21.4% of pediatric patients.Our study supports SRS as a viable modality for pediatric and adult patients with grade 2 and 3 ependymomas. Despite lower local tumor control in pediatric and grade 3 cases, integrating SRS holds promise for improved outcomes. Emphasizing careful patient selection, personalized treatment planning, and long-term follow-up is crucial for optimal neurosurgical outcomes.

  View details for DOI 10.1227/neu.0000000000002979

  View details for PubMedID 38785440

• Percutaneous Disc Biopsy versus Bone Biopsy for the Identification of Infectious Agents in Osteomyelitis/Discitis. Journal of vascular and interventional radiology : JVIR Zamarud, A., Kesten, J., Park, D. J., Pulli, B., Telischak, N. A., Dodd, R. L., Do, H. M., Marks, M. P., Heit, J. J. 2024

  Abstract

  To determine whether sampling of the disc or bone is more likely to yield positive tissue culture results in patients with vertebral discitis and osteomyelitis (VDO).Retrospective review was performed of consecutive patients who underwent vertebral disc or vertebral body biopsy at a single institution between February 2019 and May 2023. Inclusion criteria were age ≥18 years, presumed VDO on spinal magnetic resonance (MR) imaging, absence of paraspinal abscess, and technically successful percutaneous biopsy with fluoroscopic guidance. The primary outcome was a positive biopsy culture result, and secondary outcomes included complications such as nerve injury and segmental artery injury.Sixty-six patients met the inclusion criteria; 36 patients (55%) underwent disc biopsy, and 30 patients (45%) underwent bone biopsy. Six patients required a repeat biopsy for an initially negative culture result. No significant demographic, laboratory, antibiotic administration, or pain medication use differences were observed between the 2 groups. Patients who underwent bone biopsy were more likely to have a history of intravenous drug use (26.7%) compared with patients who underwent disc biopsy (5.5%; P = .017). Positive tissue culture results were observed in 41% of patients who underwent disc biopsy and 15% of patients who underwent bone biopsy (P = .016). No vessel or nerve injuries were detected after procedure in either group.Percutaneous disc biopsy is more likely to yield a positive tissue culture result than vertebral body biopsy in patients with VDO.

  View details for DOI 10.1016/j.jvir.2024.02.016

  View details for PubMedID 38613536

• Therapeutic approaches for spinal synovial sarcoma: a comprehensive review of the literature. Journal of neurosurgery. Spine Zamarud, A., Shahnoor, S., Maryyum, A., Khan, A. M., Hassan, K. M., Ijaz, A., Sayed, R., Yoo, K., Park, D. J., Chang, S. D. 2024: 1-8

  Abstract

  Synovial sarcoma (SS) is a relatively rare type of soft-tissue sarcoma that is commonly treated with surgery, radiation, chemotherapy, and palliative care. Stereotactic radiosurgery (SRS) is an emerging approach that shows promise in treating CNS conditions, but it has not been studied for SS. The authors present a systematic review that explores the effectiveness of different treatments, with a focus on SRS, for managing spinal SS.A systematic PubMed search was conducted that covered studies from 1964 to 2022, yielding 70 relevant studies. Inclusion criteria encompassed primary and metastatic spinal SS, various treatment modalities, patient age 17 years or older, English-language studies, retrospective series, and case reports. Based on these criteria, 26 studies were included in this review and 44 were excluded.Of the included studies, 15 patients from 9 studies were treated with surgical intervention followed by both conventional radiotherapy (RT) and chemotherapy, 10 patients from 10 studies were treated with surgery followed by RT, 5 studies comprising 8 patients were exclusively treated with surgery, 5 cases in 3 studies were treated with surgery plus concomitant chemotherapy, 4 patients in 2 studies were treated with SRS, and only 1 study reported treatment without surgery and with chemotherapy and RT. The median progression-free survival and overall survival periods observed in the SRS-treated patients were 37 months and 60 months, respectively, which were higher than those of any other treatment method or combination used.The authors' study offers a thorough review of spinal SS treatments. They are hopeful that this will aid clinicians in informed decision-making for better patient outcomes.

  View details for DOI 10.3171/2024.1.SPINE231184

  View details for PubMedID 38489819

• Belzutifan Reduction of Cerebral Blood Flow in VHL-Associated Hemangioblastoma Predicts Response to Treatment. Persad, A. R., Yagmurlu, A. B., Park, D. J., Zamarud, A., Huang, Y., Hori, Y. S., Chang, S. D., Iv, M. 2024

  View details for DOI 10.1093/neuonc/noae165.0848

• Surgery and stereotactic radiosurgery for spinal leiomyosarcoma: a single-institution retrospective series and systematic review. Journal of neurosurgery. Spine Zamarud, A., Marianayagam, N. J., Sekar, V., Testa, S., Park, D. J., Yener, U., McCleary, T. L., Yoo, K. H., Emrich, S., Tayag, A., Ustrzynski, L., Pollom, E., Soltys, S., Wang, L., Charville, G., Ganjoo, K., Chang, S. D., Meola, A. 2023: 1-13

  Abstract

  Leiomyosarcoma (LMS) is a rare, aggressive soft-tissue sarcoma that seldom spreads to the bone. The spine can be either the site of LMS osseous metastases or the primary tumor site. The optimal treatment option for spinal LMS is still unclear. The authors present a cohort of patients with spinal LMS treated with either upfront surgery or upfront CyberKnife stereotactic radiosurgery (SRS).The authors retrospectively studied the clinical and radiological outcomes of 17 patients with spinal LMS treated at their institution between 2004 and 2020. Either surgery or SRS was used as the upfront treatment. The clinical and radiological outcomes were assessed. A systematic review of the literature was also conducted.Of the 17 patients (20 spinal lesions), 12 (70.6%) were female. The median patient age was 61 years (range 41-80 years). Ten patients had upfront surgery for their spinal lesions, and 7 had upfront CyberKnife radiosurgery. The median follow-up was 11 months (range 0.3-130 months). The median overall survival (OS) for the entire cohort was 13 months (range 0.3-97 months). In subgroup analysis, the median OS was lower for the surgical group (13 months, range 0.3-50 months), while the median OS for the SRS group was 15 months (range 5-97 months) (p = 0.5). Forty percent (n = 4) of those treated with surgery presented with local recurrence at a median of 6.7 months (range 0.3-36 months), while only 14% (n = 1) of those treated with CyberKnife radiosurgery had local recurrence after 5 months. Local tumor control (LTC) rates at the 6-, 12-, and 18-month follow-ups were 72%, 58%, and 43%, respectively, for the SRS group and 40%, 30%, and 20%, respectively, for the surgery group (p < 0.05). The literature review included 35 papers with 70 patients harboring spinal LMS; only 2 patients were treated with SRS. The literature review confirms the clinical and radiological outcomes of the surgical group, while data on SRS are anecdotal.The authors present the largest series in the literature of spinal LMS and the first on SRS for spinal LMS. This study shows that LTC is statistically significantly better in patients receiving upfront SRS instead of surgery. The OS does not appear different between the two groups.

  View details for DOI 10.3171/2023.10.SPINE23666

  View details for PubMedID 38157539

• Predictors of mortality in chronic subdural hematoma evacuation. Neurosurgical review Sayed, R., Gross, S., Zamarud, A., Nie, L., Mudhar, G., Eikermann, M., Rupp, S., Kim, J., Babar, M., Basam, M., Yassari, R., Gelfand, Y. 2023; 46 (1): 318

  Abstract

  Chronic subdural hematoma (cSDH) is one of the most common types of intracranial hemorrhages, particularly in the elderly. Despite extensive research regarding cSDH diagnosis and treatment, there is conflicting data on predictors of postoperative mortality (POM). We conducted a large retrospective review of patients who underwent a cSDH evacuation at a single urban institution between 2015 and 2022. Data were collected from the electronic medical record on prior comorbidities, anticoagulation use, mental status on presentation, preoperative labs, and preoperative/postoperative imaging parameters. Univariate and multivariate analyses were conducted to analyze predictors of mortality. Mortality during admission for this cohort was 6.1%. Univariate analysis showed the mortality rate was higher in those presenting with a history of dialysis. In addition, those who presented with altered mental status, were intubated, and lower GCS scores had higher rates of POM. Usage of Coumadin was correlated with higher rates of POM. Examination of preoperative labs showed that patients who presented with anemia or thrombocytopenia had higher POM. Imaging data showed that cSDH volume and greatest dimension were correlated with higher rates of POM. Finally, patients that were not extubated postoperatively had higher rates of POM. Multivariate analysis showed that only altered mental status and being not being extubated postoperatively were correlated with a higher risk of mortality. In summation, we demonstrated that altered mental status and failure to extubate were independent predictors or mortality in cSDH evacuation. Interestingly, patient age was not a significant predictor of mortality.

  View details for DOI 10.1007/s10143-023-02213-y

  View details for PubMedID 38036800

• Perineal Abscess Following SpaceOAR Insertion. Cureus Azhar, U., Lin, J., Sayed, R., Masoud, Z., Zamarud, A., Kaler, R. 2023; 15 (12): e51050

  Abstract

  This case report discussesa 64-year-old male who presented with a perineal abscess following the insertion of the SpaceOAR hydrogel, highlighting a rare but potentially serious complication of the hydrogel.Hydrogel spacers have become integral in prostate cancer radiotherapy by reducing rectal toxicity. Ensuring proper technique, prophylactic antibiotics, and vigilant post-insertion monitoring are crucial for averting complications. This case underscores the significance of early diagnosis and management in preventing severe consequences and emphasizes the need for a high index of clinical suspicion when patients present with post-insertion symptoms.

  View details for DOI 10.7759/cureus.51050

  View details for PubMedID 38146336

• Spinal metastases of pineal region glioblastoma with primitive neuroectodermal features highlighting the importance of molecular diagnoses: illustrative case. Journal of neurosurgery. Case lessons Shah, A., Marianayagam, N. J., Zamarud, A., Park, D. J., Persad, A. R., Soltys, S. G., Chang, S. D., Veeravagu, A. 2023; 6 (20)

  Abstract

  Glioblastoma (GBM) is the most common primary brain tumor with poor patient prognosis. Spinal leptomeningeal metastasis has been rarely reported, with long intervals between the initial discovery of the primary tumor in the brain and eventual spine metastasis.Here, the authors present the case of a 51-year-old male presenting with 7 days of severe headache, nausea, and vomiting. Magnetic resonance imaging of the brain and spine demonstrated a contrast-enhancing mass in the pineal region, along with spinal metastases to T8, T12, and L5. Initial frozen-section diagnosis led to the treatment strategy for medulloblastoma, but further molecular analysis revealed characteristics of isocitrate dehydrogenase-wild type, grade 4 GBM.Glioblastoma has the potential to show metastatic spread at the time of diagnosis. Spinal imaging should be considered in patients with clinical suspicion of leptomeningeal spread. Furthermore, molecular analysis should be confirmed following pathological diagnosis to fine-tune treatment strategies.

  View details for DOI 10.3171/CASE23536

  View details for PubMedID 37956418

• The outcome of central nervous system hemangioblastomas in Von Hippel-Lindau (VHL) disease treated with belzutifan: a single-institution retrospective experience. Journal of neuro-oncology Zamarud, A., Marianayagam, N. J., Park, D. J., Yener, U., Yoo, K. H., Meola, A., Chang, S. D. 2023

  Abstract

  Belzutifan is a Hypoxia Inducible Factor 2-alpha inhibitor approved in 2021 by the FDA for the treatment of renal cell carcinoma (RCC) in patients with Von-Hippel Landau (VHL) disease. These patients can also present with central nervous system (CNS) hemangioblastomas (HBs). We aim to study the effectiveness and adverse effects of belzutifan for CNS HBs, by reporting our preliminary institutional experience.We present a series of VHL patients with CNS HBs undergoing treatment with belzutifan for RCC. All the included patients met the RECIST inclusion criteria. The clinical and radiological outcome measures included: Objective response rate (ORR), time-to-response (TTR), adverse events (AE), and patient response. Patient response was classified as partial response (PR), complete response (CR), progressive disease (PD), or stable disease (SD).Seven patients with 25 HBs were included in our study. A belzutifan dose of 120 mg/day PO was administered for a median of 13 months (range 10-17). Median follow up time was 15 months (range 10-24). An ORR of 71% was observed. The median TTR was 5 months (range: 1-10). None of the patients showed CR, while 5 patients (71.4%) showed PR and 2 (28.5%) showed SD. Among patients with SD the maximum tumor response was 20% [increase/decrease] of the lesion diameter. All the patients experienced decreased hemoglobin concentration, fatigue, and dizziness. None of the patients experienced severe anemia (grade 3-4 CTCAE).Belzutifan appears to be an effective and safe treatment for CNS hemangioblastoma in VHL patients. Further clinical trials to assess the long-term effectiveness of the medication are required.

  View details for DOI 10.1007/s11060-023-04496-z

  View details for PubMedID 37955759

  View details for PubMedCentralID 5573741

• STEREOTACTIC RADIOSURGERY FOR RESIDUAL, RECURRENT, AND METASTATIC HEMANGIOPERICYTOMAS: A SINGLE INSTITUTION EXPERIENCE Yoo, K., Park, D., Veeravagu, A., Lee, M., Marianayagam, N., Zamarud, A., Gu, X., Pollom, E., Soltys, S., Chang, S., Meola, A. OXFORD UNIV PRESS INC. 2023

  View details for Web of Science ID 001115245400225

• Ultrasound guided versus conventional Fluoroscopy guided epidural injection for radiculopathy. A meta-analysis of Randomized Controlled Trials. World neurosurgery Ahmed, M., Ahmad, A., Arshad, M., Naseer, H., Zamarud, A. 2023

  Abstract

  Radiculopathy, a painful condition due to the irritation of a spinal nerve root, is a common neurosurgical presentation. Apart from its conventional treatment with pain killers and surgical management, it can also be managed with epidural steroid injections (ESIs).The objective of this study is to compare ultrasound (USG) guidance with conventional fluoroscopy guidance for ESIs to treat radiculopathy.PubMed, Embase, Clinicaltrials.gov, and Cochrane were systematically searched and RCTs comparing USG with conventional fluoroscopy for ESIs in the case of radiculopathy were included. Web Revman was used for data analysis.The Literature search resulted in 640 studies, of which 7 studies were included in this meta-analysis after extensive screening. There was no statistically significant difference in pain reduction between USG and Fluoroscopy groups especially in the case of lumbosacral spinal level at 1 month [mean difference (MD)-0.12(-0.47-0.23)] and at 3 months [MD 0.73(-1.49, 2.96)]. Similarly, functional improvement after ESIs was comparable between the two groups. The Risk of inadvertent vascular puncture in USG guided ESIs was lower as compared to conventional fluoroscopy guided ESIs [Odds Ratio (OR) 0.21(0.07, 0.64)]. Furthermore, the procedure time in the USG group was also significantly lower as compared to fluoroscopy group.USG guided ESIs are not only comparable to conventional fluoroscopy guided ESIs in terms of pain control and functional improvement, particularly evident at the lumbosacral spinal level, but also have a lower risk of inadvertent vascular puncture.

  View details for DOI 10.1016/j.wneu.2023.09.088

  View details for PubMedID 37774791

• Stereotactic Radiosurgery for Medically Refractory Trigeminal Neuralgia Secondary to Stroke: A Systematic Review and Clinical Case Presentation. World neurosurgery Zamarud, A., Park, D. J., Ung, T. H., McCleary, T. L., Yoo, K. H., Soltys, S. G., Lim, M., Chang, S. D., Meola, A. 2023

  View details for DOI 10.1016/j.wneu.2023.08.092

  View details for PubMedID 37640262

• Navigating Glioblastoma Diagnosis and Care: Transformative Pathway of Artificial Intelligence in Integrative Oncology. Cureus Ibrahim, M., Muhammad, Q., Zamarud, A., Eiman, H., Fazal, F. 2023; 15 (8): e44214

  Abstract

  Glioblastoma multiforme (GBM), an aggressive brain tumor with high recurrence rates and limited survival, presents a pressing need for accurate and timely diagnosis. The interpretation of MRI can be complex and subjective. Artificial Intelligence (AI) has emerged as a promising solution, leveraging its potential to revolutionize diagnostic imaging. Radiomics treats images as numerical data and extracts intricate features from images, including subtle patterns that elude human observation. By integrating radiomics with genetics through radiogenomics, AI aids in tumor classification, identifying specific mutations and genetic traits. Furthermore, AI's impact extends to treatment planning. GBM's heterogeneity and infiltrative growth complicate delineation for treatment purposes. AI-driven segmentation techniques provide accurate 2D and 3D delineations, optimizing surgical and radiotherapeutic planning. Predictive features like angiogenesis and tumor volumes enable AI models to anticipate postop complications and survival rates. It can also aid in distinguishing posttreatment radiation effects from tumor recurrence. Despite these merits, concerns linger. The quality of medical data, transparency of AI techniques, and ethical considerations require thorough addressing. Collaborative efforts between neurosurgeons, data scientists, ethicists, and regulatory bodies are imperative for AI's ethical development and implementation. Transparent communication and patient consent are vital, fostering trust and understanding in AI-augmented medical care. In conclusion, AI holds immense promise in diagnosing and managing aggressive brain tumors like GBM. Its ability to analyze complex radiological data, integrate genetics, and aid in treatment planning underscores its potential to transform patient care. However, carefully considering ethical, technical, and regulatory aspects is crucial for realizing AI's full potential in oncology.

  View details for DOI 10.7759/cureus.44214

  View details for PubMedID 37645667

• Stereotactic radiosurgery for distant brain metastases secondary to esthesioneuroblastoma: a single-institution series. Neurosurgical focus Zamarud, A., Yener, U., Yoo, K. H., Park, D. J., Marianayagam, N. J., Ho, Q. A., Pollom, E., Soltys, S., Wang, L., Chang, S. D., Meola, A. 2023; 55 (2): E6

  Abstract

  Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare, malignant tumor of neuroectodermal origin that arises from the olfactory neuroepithelium. In this study the authors present the first series in the literature on distant brain metastases (BMs) secondary to ENB that were treated with stereotactic radiosurgery (SRS), to evaluate the safety and effectiveness of SRS for this indication.A retrospective analysis of clinical and radiological outcomes of patients with ENB who underwent CyberKnife (CK) SRS at a single center was conducted. The clinical and radiological outcomes of patients, including progression-free survival, overall survival, and local tumor control (LTC) were reported.Between 2003 and 2022, 32 distant BMs in 8 patients were treated with CK SRS at Stanford University. The median patient age at BM diagnosis was 62 years (range 47-75 years). Among 32 lesions, 2 (6%) had previously been treated with surgery, whereas for all other lesions (30 [94%]), CK SRS was used as their primary treatment modality. The median target volume was 1.5 cm3 (range 0.09-21.54 cm3). CK SRS was delivered by a median marginal dose of 23 Gy (range 15-30 Gy) and a median of 3 fractions (range 1-5 fractions) to a median isodose line of 77% (range 70%-88%). The median biologically effective dose was 48 Gy (range 21-99.9 Gy) and the median follow-up was 30 months (range 3-95 months). The LTC at 1-, 2-, and 3-year follow-up was 86%, 65%, and 50%, respectively. The median progression-free survival and overall survival were 29 months (range 11-79 months) and 51 months (range 15-79 months), respectively. None of the patients presented adverse radiation effects.In the authors' experience, SRS provided excellent LTC without any adverse radiation effects for BMs secondary to ENB.

  View details for DOI 10.3171/2023.5.FOCUS23216

  View details for PubMedID 37527675

• Stereotactic radiosurgery for sarcoma metastases to the brain: a single-institution experience. Neurosurgical focus Zamarud, A., Park, D. J., Dadey, D. Y., Yoo, K. H., Marianayagam, N. J., Yener, U., Szalkowski, G. A., Pollom, E., Soltys, S., Chang, S. D., Meola, A. 2023; 55 (2): E7

  Abstract

  Brain metastases (BMs) secondary to sarcoma are rare, and their incidence ranges from 1% to 8% of all bone and soft tissue sarcomas. Although stereotactic radiosurgery (SRS) is widely used for BMs, only a few papers have reported on SRS for sarcoma metastasizing to the brain. The purpose of this study was to evaluate the safety and effectiveness of SRS for sarcoma BM.The authors retrospectively reviewed the clinical and radiological outcomes of patients with BM secondary to histopathologically confirmed sarcoma treated with SRS, either as primary treatment or as adjuvant therapy after surgery, at their institution between January 2005 and September 2022. They also compared the outcomes of patients with hemorrhagic lesions and of those without.Twenty-three patients (9 females) with 150 BMs secondary to sarcoma were treated with CyberKnife SRS. Median age at the time of treatment was 48.22 years (range 4-76 years). The most common primary tumor sites were the heart, lungs, uterus, upper extremities, chest wall, and head and neck. The median Karnofsky Performance Status on presentation was 73.28 (range 40-100). Eight patients underwent SRS as a primary treatment and 15 as adjuvant therapy to the resection cavity. The median tumor volume was 24.1 cm3 (range 0.1-150.3 cm3), the median marginal dose was 24 Gy (range 18-30 Gy) delivered in a median of 1 fraction (range 1-5) to a median isodose line of 76%. The median follow-up was 8 months (range 2-40 months). Median progression-free survival and overall survival were 5.3 months (range 0.4-32 months) and 8.2 months (range 0.1-40), respectively. The 3-, 6-, and 12-month local tumor control (LTC) rates for all lesions were respectively 78%, 52%, and 30%. There were no radiation-induced adverse effects. LTC at the 3-, 6-, and 12-month follow-ups was better in patients without hemorrhagic lesions (100%, 70%, and 40%, respectively) than in those with hemorrhagic lesions (68%, 38%, and 23%, respectively).SRS, both as a primary treatment and as adjuvant therapy to the resection cavity after surgery, is a safe and relatively effective treatment modality for sarcoma BMs. Nonhemorrhagic lesions show better LTC than hemorrhagic lesions. Larger studies aiming to validate these results are encouraged.

  View details for DOI 10.3171/2023.5.FOCUS23168

  View details for PubMedID 37527671

• CyberKnife Radiosurgery for Spinal Leptomeningeal Metastases Secondary to Esthesioneuroblastoma: A Clinical Case Report. Cureus Zamarud, A., Yener, U., Sayed, R., Chang, S. D., Meola, A. 2023; 15 (5): e39791

  Abstract

  Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare malignant tumor of neuroectodermal origin that arises from the olfactory epithelium. We present a case of ENB metastasizing through the leptomeningeal route to the spinal dura, which was treated with CyberKnife (CK) stereotactic radiosurgery (SRS), and aim to assess the safety and effectiveness of SRS in such cases. To the best of our knowledge, this is the first case report in the literature that discusses ENB spinal leptomeningeal metastases treated with CK radiosurgery. We retrospectively reviewthe clinical and radiological outcomes in a 70-year-old female with ENB metastasis to the spine. Progression-free survival (PFS), overall survival (OS), and local tumor control (LTC) are investigated. In our patient, ENB had been diagnosedat the age of 58 yearsand spinal metastases had been first noted at the age of 65 years. A total of six spinal lesions received CK SRS. Lesions were present at the level of C1, C2, C3, C6-C7, T5, and T10-11.The median target volume was 0.72 cc (range: 0.32-2.54). A median marginal dose of 24 Gy was delivered to the tumors with a median of three fractions to a median isodose line of 80% (range: 78-81). LTC at the 24-monthfollow-up was 100%. PFS and OS were 27 months and 40 months, respectively. No adverse radiation effects were reported. Even though the treated spinal lesions remained stable, the number of new metastatic lesions had increased with progressive osseous and dural metastatic lesions within the cervical, thoracic, and lumbar spine at the last follow-up. SRS provides relatively good LTC for patients with ENB metastasizing to the spine, with no radiation-induced adverse events.

  View details for DOI 10.7759/cureus.39791

  View details for PubMedID 37398775

• Cyberknife Radiosurgery for Synovial Sarcoma Metastasizing to the Spine: Illustrative Case Reports. Cureus Zamarud, A., Park, D. J., Haider, G., Chang, S. D., Meola, A. 2023; 15 (4): e37087

  Abstract

  Synovial sarcoma (SS) is a rare and aggressive type of soft tissue sarcoma that commonly affects young adults. Metastasis in the spine is a rare complication, and the management of these lesions is challenging. Radiosurgery is an increasingly popular treatment option for spinal metastasis due to its ability to deliver high doses of radiation to the target volume with minimal exposure to surrounding healthy tissues. In this paper, we present two cases of SS with spinal metastasis that were treated with CyberKnife radiosurgery (CKRS). The first case was a 52-year-old female with a history of multiple thoracotomies and lobectomies for lung metastases, who was diagnosed with T6-T8 and T4 spinal metastasis. The second case was a 53-year-old female with Down syndrome, who was diagnosed with T12-L1 spinal metastasis. Both patients experienced an improvement in their symptoms following CKRS treatment and showed stable or decreasing lesion sizes on follow-up imaging. The progression-free survival (PFS) in the first case was 37 months and overall survival (OS) was 79 months. In the second case, the PFS was 12 months and OS was 18 months. These cases highlight the potential benefits of CKRS as a treatment option for SS with spinal metastasis and support its use in the management of this challenging condition.

  View details for DOI 10.7759/cureus.37087

  View details for PubMedID 37168194

  View details for PubMedCentralID PMC10166278

• Treatment Outcomes of Leiomyosarcoma Metastasis Affecting the Brachial Plexus: A Comparative Case Report Using Chat Generative Pre-trained Transformer (ChatGPT). Cureus Zamarud, A., Marianayagam, N., Sekar, V., Chang, S. D., Meola, A. 2023; 15 (3): e36715

  Abstract

  Sarcomas are a rare type of cancer that can develop in various parts of the body, including the brachial plexus. Leiomyosarcomas (LMs) are a subtype of sarcoma that develops in smooth muscle tissue and can metastasize to different parts of the body. In this case report, we present two patients with LM metastasized to the brachial plexus, one treated with CyberKnife (Accuray, Sunnyvale, CA) stereotactic radiosurgery (CK SRS) and the other with surgical resection. The aim of this case report is to present the treatment outcomes and adverse effects of CK SRS and surgical resection in brachial plexus LM metastasis. Patient 1 was a 39-year-old female who received CK SRS, and at three months of follow-up, the lesion was smaller, and she reported symptomatic improvement. At 15 months, the lesion was stable in size, and there was no evidence of local invasion of the adjacent vascular structures or nerves. Patient 2 was a 52-year-old male who underwent surgical resection, and at one-month follow-up, the patient was asymptomatic with no recurrence of his symptoms. The size of the residual axillary tumor was stable at three months and showed a slight interval decrease in size at five months of follow-up. He was followed for over 12 months, with no recurrence of his symptoms. Both treatments appear to have been effective in controlling LM growth and relieving symptoms. CK SRS provides a non-invasive option. However, more research is needed to fully understand the effectiveness and safety of these treatments for brachial plexus sarcoma. This case report highlights the importance of considering different treatment options for brachial plexus sarcoma and the need for further studies to understand the best approach for these rare cases.

  View details for DOI 10.7759/cureus.36715

  View details for PubMedID 37113342

  View details for PubMedCentralID PMC10129366

• 648 Machine Learning Predicts Cavernous Sinus Invasion of Pituitary Adenomas Neurosurgery Nernekli, K., Asmaro, K. P., Zamarud, A., et al 2023; 69 (69): 24-25

  View details for DOI 10.1227/neu.0000000000002375_648

• Cyberknife Radiosurgery for Synovial Sarcoma Metastasizing to the Spine Cureus Zamarud, A., Park, D. J., Haider, G., Chang, S. D., Meola, A. 2023; 15 (4)

  View details for DOI 10.7759/cureus.37087